Cardiology Practice Questions

Q: 274. A young athlete was found to have hypertrophic cardiomyopathy during testing for a competitive sport. Which of the following maneuvers will increase the murmur?

Valsalva maneuver. **Valsalva maneuver** - The **Valsalva maneuver** reduces **preload** by decreasing venous return to the heart. - A decrease in preload reduces the left ventricular chamber size, which in turn exacerbates the **left ventricular outflow tract (LVOT) obstruction** characteristic of hypertrophic cardiomyopathy (HCM), thereby **increasing the intensity of the murmur**. *Handgrip* - **Handgrip** is an isometric exercise that leads to an increase in **afterload** and **peripheral vascular resistance**. - Increased afterload causes the left ventricle to eject blood against higher pressure, which **enlarges the left ventricular chamber** and **reduces the LVOT obstruction**, thus **decreasing the intensity of the murmur** in HCM. *Squatting* - **Squatting** increases both **preload** (due to increased venous return) and **afterload** (due to increased peripheral vascular resistance). - The increased preload and afterload lead to an **increased left ventricular volume**, which **reduces the LVOT obstruction** and therefore **decreases the intensity of the murmur** in HCM. *Passive leg raise* - **Passive leg raise** increases **preload** by increasing venous return to the heart from the lower extremities. - The increased preload leads to an **increased left ventricular chamber size**, which **reduces the LVOT obstruction** and therefore **decreases the intensity of the murmur** in HCM. *Leaning forward* - Leaning forward during auscultation is typically used to better hear **aortic regurgitation murmurs**, as it brings the aorta closer to the chest wall. - This maneuver does not significantly alter **cardiac preload or afterload** in a way that would consistently increase the murmur of hypertrophic cardiomyopathy.

Q: A patient presents with features of heart failure. On examination, an irregularly irregular pulse is noted, and the patient has a loud diastolic sound. The jugular venous pressure (JVP) shows a rapid Y descent. What is the most likely diagnosis?

Mitral stenosis. ***Mitral stenosis*** - An **irregularly irregular pulse** suggests **atrial fibrillation**, a common complication of mitral stenosis due to left atrial enlargement. - A **loud diastolic sound**, also known as an **opening snap**, is characteristic of a stenotic mitral valve as it opens, occurring early in diastole. - The **rapid Y descent** on JVP can occur due to elevated right-sided pressures from pulmonary hypertension secondary to mitral stenosis. *Constrictive pericarditis* - While it can cause heart failure and an elevated JVP with a rapid Y descent (**Friedreich's sign**), the description of an "irregularly irregular pulse" and a "loud diastolic sound" (opening snap) is not typical. - The loud diastolic sound in constrictive pericarditis would be a **pericardial knock**, which is usually later than an opening snap and less distinct. *Cardiac tamponade* - Characterized by **Beck's triad** (hypotension, muffled heart sounds, elevated JVP) and often presents with **pulsus paradoxus**. - The JVP in tamponade typically shows an **absent or diminished Y descent**, due to impaired ventricular filling from external compression. *Aortic regurgitation* - Causes a **diastolic murmur**, but not a loud diastolic sound or opening snap. - The pulse is often a **collapsing pulse** or **water-hammer pulse**, and it is not typically irregularly irregular unless atrial fibrillation or another arrhythmia is co-existent. *Mitral regurgitation* - Can cause heart failure and atrial fibrillation, but the characteristic finding is a **pansystolic murmur**, not a loud diastolic sound. - There is no opening snap in mitral regurgitation; instead, there may be an **S3 gallop** in severe cases. - The rapid Y descent is less prominent compared to mitral stenosis.

Q: A 35-year-old male from a rural village in South Asia is admitted to the hospital with a 5-day history of high-grade fever, severe headache, and progressive breathlessness. His family reports that he has become increasingly disoriented over the past 48 hours, with episodes of confusion and drowsiness. Upon examination, the patient is febrile with a temperature of 39°C (102.2°F), tachypneic with a respiratory rate of 30 breaths per minute, and is displaying signs of altered mental status, including lethargy and difficulty following commands. His oxygen saturation is 92% on room air. There are no signs of a rash or bleeding. What is the diagnosis?

NIPAH. ***NIPAH*** - The combination of **rapidly progressive encephalitis** (disorientation, confusion, lethargy), **respiratory distress** (breathlessness, tachypnea, reduced O2 saturation), and **geographical context** (rural South Asia) strongly points towards NIPAH virus infection. - **Bats** (specifically fruit bats) are the natural reservoir for NIPAH virus, and exposure to bat secretions or contaminated food can lead to outbreaks, especially in rural areas where the image suggests bats are present. - The **distinctive combination of severe respiratory and neurological symptoms** with rapid progression is characteristic of NIPAH. *Ebola* - Ebola typically presents with **hemorrhagic fever**, characterized by severe bleeding (both internal and external), which is not described in the patient's symptoms. - While it causes high fever and altered mental status, the **prominent respiratory symptoms and lack of bleeding** make Ebola less likely. *Zika* - Zika virus infection is usually **mild or asymptomatic** and primarily transmitted by mosquitoes. - While encephalitis can occur in rare cases, the **severe respiratory distress and rapid progression of neurological symptoms** described are not typical for Zika. *Malaria* - Malaria is characterized by **cyclic fevers, chills, and sweats**, and can cause severe symptoms like cerebral malaria leading to altered mental status. - However, the patient's **pronounced respiratory symptoms and rapid onset of encephalitis without typical cyclic fever patterns** make malaria a less fitting diagnosis than NIPAH. *Japanese Encephalitis* - Japanese Encephalitis is endemic in South Asia and does cause **encephalitis with altered mental status**. - However, **prominent respiratory distress and breathlessness** are not typical features of Japanese Encephalitis, which primarily affects the central nervous system. - The **rapid progression with severe respiratory involvement** points more toward NIPAH than Japanese Encephalitis.

Q: A patient presents with large sweaty hands, macroglossia, and frontal bossing. What is the best test for confirmation of the diagnosis?

IGF-1. ***IGF-1*** - Elevated **IGF-1 (Insulin-like Growth Factor 1)** is the most reliable screening test for acromegaly, reflecting integrated GH secretion over time. - The clinical signs of **large sweaty hands**, **macroglossia**, and **frontal bossing** are classic symptoms of acromegaly, caused by excessive growth hormone (GH) production, which then stimulates IGF-1. *GHRH levels* - **Growth hormone-releasing hormone (GHRH)** levels are typically only measured when investigating ectopic GHRH production as a rare cause of acromegaly, which is not the primary diagnostic step. - While GHRH stimulates GH, its direct measurement is not the standard initial diagnostic test for suspected pituitary-driven acromegaly. *IGF-2* - **IGF-2 (Insulin-like Growth Factor 2)** plays a role in fetal growth and certain tumor-related syndromes, but it is not the primary mediator or diagnostic marker for acromegaly in adults. - IGF-1, not IGF-2, is the main growth factor responsible for the anabolic effects of growth hormone. *GH levels after glucose suppression* - Measuring **GH levels after glucose suppression** (oral glucose tolerance test with 75g glucose) is a confirmatory test for acromegaly, used when IGF-1 levels are equivocal or borderline. - In healthy individuals, glucose suppresses GH secretion to <1 ng/mL, but in acromegaly, GH levels remain elevated (failure to suppress), confirming autonomous GH hypersecretion. *Random GH level* - **Random GH levels** are unreliable for diagnosing acromegaly due to the pulsatile nature of GH secretion, with significant variation throughout the day. - A single normal GH level does not exclude acromegaly, and a single elevated level can occur in healthy individuals during normal secretory peaks, making it inadequate as a diagnostic test.

Q: What is the most common cause of death in idiopathic pulmonary fibrosis (IPF)?

Respiratory failure. ***Respiratory failure*** - **Progressive fibrosis** of the lung tissue in idiopathic pulmonary fibrosis (IPF) directly impairs gas exchange, leading to **hypoxemia** and hypercapnia. - This deterioration ultimately culminates in **respiratory failure**, which is the primary cause of mortality in most IPF patients. *Pulmonary edema* - While pulmonary edema can occur in systemic conditions, it is not the **primary or most common cause of death** specifically in IPF. - IPF is characterized by **fibrotic remodeling**, not primarily fluid overload in the alveoli. *Cancer* - Patients with IPF have an **increased risk of lung cancer**, but it is not the most common cause of death compared to respiratory failure. - The development of cancer is a **complication**, not the direct mechanism by which most IPF patients succumb to the disease. *Pulmonary arterial hypertension (PAH)* - PAH can be a significant complication of IPF, contributing to increased morbidity and mortality, but it is typically a **secondary contributor to death**, often by worsening respiratory mechanics. - Its presence usually **compounds respiratory failure**, rather than being the standalone, most common cause of death. *Acute exacerbation of IPF* - Acute exacerbations represent episodes of **rapid clinical deterioration** with worsening dyspnea and hypoxemia, often idiopathic or triggered by infections. - While they are a **significant cause of mortality** (accounting for a substantial proportion of IPF deaths), the underlying mechanism still relates to respiratory failure, making chronic progressive respiratory failure the most common overall cause of death.

Question 1

A patient complains of exertional syncope. He gives history of sudden death of his elder brother during a football game. Which of the following ECG findings is seen here?

Accepted Answer

Broad QRS with short PR with delta wave

Answer

Broad QRS with prolonged PR with epsilon wave

Answer

Narrow QRS with prolonged PR with Osborn wave

Answer

Narrow QRS with short PR with left ventricular hypertrophy

Answer

Deep Q waves with LVH and left atrial enlargement

Question 2

An 80-year-old lady who had previously had a few attacks of dizziness, fell and broke her hip. She was found to have slow pulse, ECG was performed. Which is the next best step for management of this patient?

Accepted Answer

Temporary pacemaker

Answer

Permanent pacemaker

Answer

ICD

Answer

Proceed with hip joint repair surgery

Answer

Atropine

Question 3

A 16-year-old boy presents with recurrent episodes of light headedness followed by syncope in school assembly. ECG was done on arrival to hospital. What is the diagnosis?

Accepted Answer

Wolff-Parkinson-White syndrome

Answer

Left ventricular hypertrophy

Answer

VT storm

Answer

ECG is normal, look for other causes of syncope

Answer

Long QT syndrome

Question 4

274. A young athlete was found to have hypertrophic cardiomyopathy during testing for a competitive sport. Which of the following maneuvers will increase the murmur?

Accepted Answer

Valsalva maneuver

Answer

Handgrip

Answer

Squatting

Answer

Leaning forward

Answer

Passive leg raise

Question 5

A patient presents with features of heart failure. On examination, an irregularly irregular pulse is noted, and the patient has a loud diastolic sound. The jugular venous pressure (JVP) shows a rapid Y descent. What is the most likely diagnosis?

Accepted Answer

Mitral stenosis

Answer

Constrictive pericarditis

Answer

Cardiac tamponade

Answer

Aortic regurgitation

Answer

Mitral regurgitation

Question 6

A 35-year-old male from a rural village in South Asia is admitted to the hospital with a 5-day history of high-grade fever, severe headache, and progressive breathlessness. His family reports that he has become increasingly disoriented over the past 48 hours, with episodes of confusion and drowsiness. Upon examination, the patient is febrile with a temperature of 39°C (102.2°F), tachypneic with a respiratory rate of 30 breaths per minute, and is displaying signs of altered mental status, including lethargy and difficulty following commands. His oxygen saturation is 92% on room air. There are no signs of a rash or bleeding. What is the diagnosis?

Accepted Answer

NIPAH

Answer

Ebola

Answer

Zika

Answer

Malaria

Answer

Japanese Encephalitis

Question 7

A 32-year-old female presents with a 2-month history of progressive, painless swelling in the left side of her neck. She also reports low-grade fever, night sweats, and unintentional weight loss. Physical examination reveals a firm, non-tender, immobile mass in the left cervical region, and multiple smaller lymph nodes in the supraclavicular area. Chest X-ray shows mediastinal widening, and a lymph node biopsy confirms the presence of Reed-Sternberg cells. What is the most appropriate management for this patient?

Accepted Answer

Hodgkin Lymphoma with the ABVD regimen

Answer

NHL with a highly aggressive chemotherapy regimen

Answer

NHL with Rituximab

Answer

Hodgkin Lymphoma with surgical excision only

Answer

Hodgkin Lymphoma with radiation therapy only

Question 8

A 45-year-old patient presents with hypertension, hematuria, and flank pain. An MRI scan is performed, and the image provided shows multiple cystic lesions in both kidneys. What is the most likely diagnosis?

Accepted Answer

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

Answer

Renal cyst

Answer

Renal tumor

Answer

Chronic kidney disease with cystic degeneration

Answer

Acquired cystic kidney disease

Question 9

A patient presents with large sweaty hands, macroglossia, and frontal bossing. What is the best test for confirmation of the diagnosis?

Accepted Answer

IGF-1

Answer

GHRH levels

Answer

IGF-2

Answer

GH levels after glucose suppression

Answer

Random GH level

Question 10

What is the most common cause of death in idiopathic pulmonary fibrosis (IPF)?

Accepted Answer

Respiratory failure

Answer

Pulmonary edema

Answer

Cancer

Answer

Pulmonary arterial hypertension (PAH)

Answer

Acute exacerbation of IPF

Cardiology — MCQs

Cardiology — MCQs

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